CMS/EIP Fiscal Report Center: 57
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 Page: 1
Payclass Filters:GR
Eligibility Filter:Program Patients
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 320 214.75 7945.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 679 693.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 245 221.00 8177.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 706 2762.75 102221.75 37.00
TCON-TCON-TRANSITION CONFERENCE 180 185.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 1186 4076.50 118344.50 29.03
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 5 6.00 300.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 79 79.00 3950.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 6.50 487.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.00 75.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 7.50 416.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 163 190.00 14250.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 6.00 450.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 164 255.00 14152.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 12.00 900.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 9 9.00 436.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 8 8.00 388.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 5 5.00 242.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 10 11.00 533.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 79 80.00 3880.00 48.50
Subtotal (Total Children Is Unduplicated) 353 677.00 40536.75 59.88
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.00 50.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 162 211.75 10587.50 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 37 42.50 1062.50 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 1.00 50.00 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 9 8.00 400.00 50.00
CONPP-CONPP-CONSULT, PT, PHONE 1 1.00 25.00 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 197 265.50 13275.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 36 42.50 1062.50 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 354 2879.50 143975.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 56 215.32 14616.03 67.88
PHY-97110-PT SESSION BY LICENSED PT 46 139.25 9452.29 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 302 1423.21 96607.43 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 803 173630 90377.40 0.52
Subtotal (Total Children Is Unduplicated) 971 178861 381540.65 2.13
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Total 183614.03 540421.90 2.94
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Number of Children (Unduplicated) With at Least One Service 1496
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Center 57
Flag Claims Units Chgs Paid
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R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 2 2.00 74.00 0.00
P 0 0.00 0.00 0.00
D 6 2.75 101.75 0.00
S 147 4700.00 7488.08 7565.66
H 0 0.00 0.00 0.00
T 4605 174220.03 378322.37 378368.19
4727 4683.75 154124.94 289.02
Other 5 5.50 310.76 310.76
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Total 9492 183614.03 540421.90 386533.63